Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early.

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Presentation on theme: "Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early."— Presentation transcript:

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Asthma A Chronic disease of the airways that may cause: WheezingWheezing BreathlessnessBreathlessness Chest tightnessChest tightness Nighttime or early morning coughingNighttime or early morning coughing

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The rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contractionThe rapidly reversible airflow obstruction of asthma is mainly due to bronchial smooth muscle contraction

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Focus of Therapy Pharmacologic manipulation of airway smooth musclePharmacologic manipulation of airway smooth muscle Do not overlook physiologic impairment caused by mucous production and mucosal edemaDo not overlook physiologic impairment caused by mucous production and mucosal edema Bronchospasm can be reversed in minutesBronchospasm can be reversed in minutes Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks -Airflow obstruction due to mucous plugging and inflammatory changes in bronchial walls may not resolve for days/weeks - may lead to atelectasis, infectious bronchitis, pneumonitismay lead to atelectasis, infectious bronchitis, pneumonitis

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Patient Exam Hyperrsonance to percussionHyperrsonance to percussion decreased intensity of breath soundsdecreased intensity of breath sounds prolongation of expiratory phase w or w/o wheezingprolongation of expiratory phase w or w/o wheezing The intensity of the wheeze may not correlate with the severity of airflow obstructionThe intensity of the wheeze may not correlate with the severity of airflow obstruction “quiet chest” - very severe airflow obstruction“quiet chest” - very severe airflow obstruction

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Risk factors for death from asthma: Past history of sudden severe exacerbations Prior intubation for asthma Prior admission for asthma to an intensive care unit Two or more hospitalizations for asthma in the past year Three or more emergency care visits for asthma in the past year Hospitalization or emergency care visit for asthma within the past month Use of more than two canisters per month of inhaled short-acting 2-agonist Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids Difficulty perceiving airflow obstruction or its severity Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease Serious psychiatric illness or psychosocial problems Low socioeconomic status in urban residents Illicit drug use

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medications are used in the treatment of acute asthma adrenergic agonistsadrenergic agonists anticholinergicsanticholinergics glucocorticoidsglucocorticoids Magnesium, heliox (mixture of helium and oxygen), and ketamine may be considered when the aforementioned medications fail to relieve bronchospasm.Magnesium, heliox (mixture of helium and oxygen), and ketamine may be considered when the aforementioned medications fail to relieve bronchospasm. Mast cell-stabilizing agents, methylxanthines, and leukotriene modifiers are currently reserved for maintenance therapy onlyMast cell-stabilizing agents, methylxanthines, and leukotriene modifiers are currently reserved for maintenance therapy only

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Albuterol (MDI) Meter Dose Inhalation (90μ/puff) (MDI) Meter Dose Inhalation (90μ/puff) 4–8 puffs every 20 min up to 4 h4–8 puffs every 20 min up to 4 h then every 1–4 h as needed then every 1–4 h as needed As effective as nebulized therapy if patient is able to coordinate inhalation maneuver; use spacer/holding chamberAs effective as nebulized therapy if patient is able to coordinate inhalation maneuver; use spacer/holding chamber

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Anticholinergics Ipratropium bromide Ipratropium bromide Nebulizer solution (0.2 mg/mL) Nebulizer solution (0.2 mg/mL) 0.5 mg every 30 min for 3 doses0.5 mg every 30 min for 3 doses then every 2–4 h as neededthen every 2–4 h as needed Should not be used as first-line therapy;Should not be used as first-line therapy; should be added to 2 agonist therapy;should be added to 2 agonist therapy; may mix in same nebulizer with albuterolmay mix in same nebulizer with albuterol MDI (18 g/puff)MDI (18 g/puff) 4–8 puffs every 6–8 h4–8 puffs every 6–8 h

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Corticosteroids administered within 1 h of arrival in the EDadministered within 1 h of arrival in the ED reduces the need for hospitalization prednisone 40 to 60 mg, oral methylprednisolone 60 to 125 mg IV High-dose corticosteroid therapy offers no advantageHigh-dose corticosteroid therapy offers no advantage Additional doses should be given every 4 to 6 h until significant subjective and objective improvements are achieved Additional doses should be given every 4 to 6 h until significant subjective and objective improvements are achieved discharging all patients with mild persistent or more severe asthma on maintenance inhaled corticosteroids in addition to a burst of oral corticosteroiddischarging all patients with mild persistent or more severe asthma on maintenance inhaled corticosteroids in addition to a burst of oral corticosteroid

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Corticosteroids Corticosteroids PrednisonePrednisone MethylprednisoloneMethylprednisolone PrednisolonePrednisolone 120–180 mg per d in 3 or 4 divided doses for 48 h,120–180 mg per d in 3 or 4 divided doses for 48 h, then 60–80 mg per d until FEV1, or PEFR reaches 70% of predicted or personal best then 60–80 mg per d until FEV1, or PEFR reaches 70% of predicted or personal best For outpatient "burst," use 40–60 mg per d, for 3–10 d in adultsFor outpatient "burst," use 40–60 mg per d, for 3–10 d in adults

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Theophylline no longer considered a first-line treatmentno longer considered a first-line treatment in combination with inhaled B 2-adrenergic drugs,in combination with inhaled B 2-adrenergic drugs, increase the toxicity, but not the efficacy, of treatmentincrease the toxicity, but not the efficacy, of treatment more sustained bronchodilator effect, improving respiratory muscle endurancemore sustained bronchodilator effect, improving respiratory muscle endurance improving resistance to fatigueimproving resistance to fatigue anti-inflammatoryanti-inflammatory side effects nervousness, nausea, vomiting, anorexia, and headachenervousness, nausea, vomiting, anorexia, and headache At plasma levels greater than 30 g/mL, there is a risk of seizures and cardiac arrhythmias. At plasma levels greater than 30 g/mL, there is a risk of seizures and cardiac arrhythmias.

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Mechanical Ventilation progressive hypercarbia and acidosisprogressive hypercarbia and acidosis ExhaustedExhausted confused,confused, does not relieve the airflow obstruction eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolveddoes not relieve the airflow obstruction eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolved Direct oral intubationDirect oral intubation